Dissociative Identity Disorder: Ethically Unsplitting the Split Personality

On the last track we discussed mapping the personality system.  Three steps to mapping the personality system are choosing a form of map, identifying useful information, and using maps as final integration tools. 

On this track we will discuss therapeutic resolutions.  In his book, “Diagnosis & Treatment of Multiple Personality Disorder,” Frank Putnam provides therapeutic resolutions consisting of techniques for fusion and integration, assessing fusion stability, therapeutic interventions for fusion failures, and post-fusion treatment.

4 Therapeutic Resolutions

#1  Techniques for Fusion and Integration
First, let’s discuss techniques for fusion and integration.  The therapy of DID proceeds stepwise through a series of issues and stages.  How do you determine if your DID client’s alters are ready to begin fusion and integration work?  I find that signs suggesting that two or more alters are ready for fusion usually indicate that the dissociative barriers maintaining separateness have eroded to a point where fusion is possible. 

The alters may report coconsciousness or other forms of simultaneously shared awareness.  A nondysphoric, persistent sense of simultaneous copresence is a strong indicator that two or more alters are ready to attempt fusion.  The alters may report an “identity crisis,” in that they do not feel the way they used to and have a blurred or overlapping sense of identity.  The alters may also report themselves ready to fuse or request that the therapist help them fuse.  One client’s alters requested fusion from a colleague of mine because he claimed that continued separateness felt uncomfortable.

As you know, successful fusions can only occur after the dissociative defensive barriers that serve to separate the alters have been significantly eroded by psychotherapy.  This happens when the alters begin to accept each other and to develop a sense of mutual self-identification.  Each will also acknowledge memories possessed by the other alter, and other issues for which the alter in question was previously amnesic or denied knowledge.  

At this point, the alters will often indicate that they are uncomfortable with their separateness and report experiences of coconsciousness and feelings of being redundant.  The therapist then spends some time searching for residual areas of conflict between the alters. Each alter should be offered the opportunity to talk about any latent issues and probe for hidden conflicts.  If any problems remain, do you agree that these must be worked through until no further issues divide the alters to be fused?

The next step usually involves a formal procedure, sometimes augmented by hypnosis.  Most formal procedures used involve the use of visual imagery and metaphors and are generally performed while the alters are in trance-like state.  The image or metaphor employed should be discussed ahead of time with the alters and the client as a whole.  Some apparently innocuous images may have highly charged meanings for the alters or client and may thus be detrimental to the fusion process.  What types of images might you use to foster fusion or integration with your client? 

I find that using images of embrace, dance, and other shared activities can be productive.  My colleague George prefers images of the blending together of light or the flowing together of water.  George calls forth the two alters to be fused and asks that they “stand” side by side, and then incorporates them into the hypnotically enhanced imagery.  

The alters may then be told that they are surrounded by a glowing ball of light, and that as their light blends together, they also blend together to become a single glowing ball of light.  George stresses that images of blending in which all elements are preserved and represented in the larger whole are preferable to images or metaphors that suggest death, elimination, subtraction, or banishment.  

Do you agree?  DID clients seem to need and demand a fusion technique, although the fusion process usually appears to be taking place on its own with the development of coconsciousness, the erosion of dissociative barriers, and the alters’ increasing discomfort with separateness.  Final fusions—that is, fusions in which all of the alters are blended into a single entity—are simply extensions of the techniques described above.

Usually final fusions are preceded by a series of partial fusions that consolidate the alters into two or more composite personalities, which then undergo the final fusion. Final fusions may be accompanied by changes in sensory perception by the patient. I have heard several clients spontaneously report that sounds were clearer and “less muffled”, colors were brighter, and vision was sharper following a final integration. 

#2  Assessing Fusion Stability
Due to a high rate of relapse and/or failure to fuse in the first place, do you test your DID clients actively for evidence of fusion/integration stability.  A formal interview protocol for assessing the stability of fusions in your clients may begin by inquiring about signs and symptoms of DID in general, and then focusing on signs and symptoms that were specific to the client during the course of treatment.  You might consider asking your client to provide a chronology of his or her interim history, and is also asked about the observations and opinions of others with regard to the fusion. 

In my practice, I then attempt to elicit every one of the client&rsqu